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MENNONITE COLLEGE OF NURSING
AT
ILLINOIS STATE UNIVERSITY
Family Nurse Practitioner III 475
Common Genitourinary Problems
Review “Urinalysis: A Comprehensive Review” at http://www.aafp.org/afp/2005/0315/p1153.html
Hematuria
Definition: > 3 RBC/HPF (although 3-5 RBC/HPF = normal in Peds)
History:
 Clots usually indicate lower urinary tract bleeding.
 Relationship to exercise may indicate runner’s hematuria
 Pain?
 Association with flank pain suggests infection, calculus, or obstruction
 Painless bleeding is associated with cancer or glomerulonephritis
 Association with hesitancy, frequency, or decreased force of stream is suggestive of prostatic
hypertrophy
 Constipated? Straining can cause minor prostatic bleeding
 Currently in menses?
 Review all medications for any which might cause hematuria, such as aspirin, NSAIDs, some
antibiotics (Cipro, Bactrim, PCN, cephalosporins), omeprazole, furosemide
Determine type of hematuria:
Initial Hematuria
Arises from a lesion within the penile or bulbous portions of the urethra
Causes may include:
 cancer
 infection
 trauma
 excessive masturbation
 foreign body such as a calculi
Total Hematuria
Present throughout the entire voiding, must have a source higher than the bladder neck in order for the
blood to thoroughly mix with the urine prior to the onset of voiding.
Such conditions may be:
 bladder, ureters, or kidney cancer
 infection,
 inflammation
 trauma of the bladder, kidney, or ureters
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TB of the bladder or kidney,
stones in the bladder or kidney.
Terminal Hematuria
Exists when the urinary stream is visibly clear until the end of voiding, at which time the last part of the
urine becomes grossly bloody, or when blood is passed from the meatus after the patient thinks that
urination has ceased.
This is usually from:
 BPH
 prostatitis,
 bladder cancer (rarely)
Source: Gleich, P. (May 2004) Hematuria: Is it from UTI or something more serious? Consultant, pp. 749-754.
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Gross hematuria usually indicates a serious problem; fairly high correlation with malignancy
(typically a transitional cell carcinoma)
Microscopically detectable blood is less likely to signal a major underlying condition; a finding of
0-3 RBCs/HPF is probably innocent
Workup for gross and microscopic hematuria focuses on disturbances of urinary tract function
and includes H&P, urinalysis, radiologic imaging, urine cytology, and cystoscopy.
Presence of hematuria, proteinuria, and renal insufficiency warrants referral to a nephrologist.
Most common causes of hematuria:
For men:
 < age 40: STDs
 > age 40: bladder cancer, BPH
For women:
 bacterial cystitis
 < age 40: UTI
 age 40-60: bladder tumors, UTI, calculi
 > age 60: bladder tumors, UTI
[Consider child abuse in children]
False-positive results from foods such as beets and blackberries, vaginal bleeding, myoglobin (exercise),
drugs, and factitious sources.
Physical Exam: VS, CV, CVA tenderness, abdomen, GU, skin (check for coagulopathy)
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The following algorithms are from: Grossfield, GD, Wolf, JS, Litwin, MS, Hricak, H, Shuler, CL, Agerter,
DC, & Carroll, PR. (2001 Mar 15). Asymptomatic microscopic hematuria in adults: Summary of the AUA
Best Practice Policy recommendations. Am Fam Physician, 63(6):1145-1155.
Initial evaluation of newly diagnosed asymptomatic microscopic hematuria.
FIGURE 1.
Initial Evaluation of Asymptomatic Microscopic Hematuria*
Adapted with permission from Grossfeld GD, Wolf JS, Litwin MS, Hricak H, Shuler CL, Agerter DC, Carroll P.
Evaluation of asymptomatic microscopic hematuria in adults: the American Urological Association best practice policy
recommendations. Part II: patient evaluation, cytology, voided markers, imaging, cystoscopy, nephrology evaluation,
and follow-up. Urology 2001;57(4).
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Urologic evaluation of asymptomatic microscopic hematuria.
FIGURE 2.
Urologic Evaluation of Asymptomatic Microscopic Hematuria
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Source: Cohen, RA & Brown, RS (June 5, 2003). Microscopic hematuria. N Engl J Med 348(23), 2330-2338.
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When asymptomatic microscopic hematuria is detected, the UA should be repeated a few days
later before any workup is initiated, especially if the patient has had vigorous exercise,
menstruation trauma to the urinary tract, or sexual activity just before the collection.
If microscopic hematuria is absent on repeated testing, no further evaluation is recommended
unless the patient has risk factors for bladder cancer or transitional-cell cancer of the urinary
tract, such as cigarette smoking or exposure to toxins.
If repeat testing shows continued microscopic hematuria, a glomerular source should be
considered, especially with the presence of red-cell casts.
o Primary care should follow-up at 6 months and then annually, to check for the
development of proteinuria or renal insufficiency.
o If microscopic hematuria is accompanied by proteinuria or renal insufficiency, the
patient should be referred to a nephrologist for evaluation.
Diagnostic Tests:
 microscopic urinalysis
 screening lab tests as appropriate (may need ANA, ASO antibody, RPR, CBC, PPD, urine for acid-fast
bacilli, PSA)
 urine cytology
 Bladder tumor antigen FISH test
 Abdominal x-ray (KUB to check for stones)
 IVP
 Renal/bladder ultrasound (to check for obstruction, anatomical defects)
 CT (without radiographic contrast medium if stone disease suspected clinically; perform without and
then with contrast for detection of stone disease or a mass (in the upper urinary tract or possibly in
the bladder)
 Refer for Cystoscopy (to check for bladder irritation, transitional cell carcinoma [TCC])
Follow-up
In 20% of patients, despite a thorough workup, the cause is still unknown. Studies of 5-year follow-up of
patients who have undergone a previously negative workup have shown that the future incidence of
serious disease is low.
Summary
 “Urine should not contain any blood.”
 Gross hematuria usually indicates a serious problem; its correlation with malignancy—typically a
transitional cell carcinoma—is fairly high.
 Microscopically detected blood is less likely to signal a major underlying condition.
 Presence of hematuria, proteinuria, and renal insufficiency warrants referral to a nephrologist.
 If hematuria persists, repeat the urinalysis and cytology every 6 months until the problem
resolves or 3 years have passed.
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Acute Urinary Tract Infection
Etiology:
 Largely a disease of sexually active females
 Female to male incidence ratio of UTI is 2:1 after age 60
 UTIs are the most common bacterial infection in the elderly and are a common source for
bacteremia
 Gram-negative coliforms are responsible for the majority of bacterial infections, with Escherichia coli
predominating.
Symptoms:
Lower Urinary Tract:
 Dysuria
 Frequency
 Nocturia
 Suprapubic pain
 Hematuria
 Malodorous urine
 Incontinence
Upper Urinary Tract:
 flank pain
 fever
 nausea and vomiting
 mental changes (in the elderly)
NOTE: Atypical presentations such as falls, change in mentation, loss of appetite, nocturia, difficulty
urinating, and new incontinence are common symptoms of UTI in elderly patients.
Clinical findings (Key signs):
Lower UTI:
 suprapubic tenderness
Upper UTI:
 flank tenderness
 fever
 tachypnea
 tachycardia
 mental status changes (in the elderly)
 vomiting
Diagnostic Tests:
Urine dip (screening test)
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biochemical screening tests include nitrite reduction and leukocyte esterase tests
These screening methods are insensitive at bacterial counts < 100,000 colony-forming units/ml.
Microscopic examination & culture of clean midstream urine
 pyuria: 10 or more WBC/ml
 In absence of a (+) culture (< 100 uropathogens/ml), pyuria suggests infection by chlamydia or
Neisseria gonorrhoeae, or tuberculosis
 WBC casts noted on microscopy strongly suggest pyelonephritis (upper UTI) in patients with UTI
symptoms
Blood culture (in toxic or elderly patients with signs of upper UTI)
Differential Diagnosis:
 Acute bacterial lower UTIs in females may be mimicked by urethritis caused by C. trachomatis, N.
gonorrhoeae, and herpes simplex virus.
 Vaginitis from Candida albicans and Trichomonas vaginalis or bacterial vaginosis also may cause
dysuria.
 Acute upper UTI can be mimicked by diverticulitis, appendicitis, pneumonia, intestinal obstruction,
and nephrolithiasis.
Making the Diagnosis:
Source: Schulz, L, Hoffman, RJ, Pothof, J, & Fox, B. (2016) Top ten myths regarding the diagnosis and treatment of urinary tract
infections. J. Emerg Med, 51(1), 25-30
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Check out the myths at http://www.medscape.com/viewarticle/865175_print ….how many have
you believed in the past?
Bottom line: Asymptomatic bacteriuria is overtreated. “Diagnosis should be based on clinical
symptoms whenever possible, and confirmed by positive urine microscopy and culture.”
Treatment:
 Acute bacterial uncomplicated lower UTIs in females
 3-5 days of oral outpatient therapy with TMP-SMX (if PCN or cephalosporin is used, must give
for 7 days)
 Fluoroquinolones: ciprofloxacin and levofloxacin
 Nitrofurantoin (5-7 days)
 Uncomplicated bacterial upper UTIs in females and males: 14 days of oral or parenteral antibiotics;
may need hospitalization (hospitalize if pregnant)
 Uncomplicated bacterial lower UTI in males: 14 days
Source: Keys, TF (July 2000). 1-Minute Consult: When should asymptomatic bacteriuria in the elderly be treated? Cleveland
Clinic Journal of Medicine, 67(7), 466-467.
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Urinary incontinence, cystoceles, and lack of estrogen are risk factors that predispose elderly
women to bacteriuria.
In men, obstructive uropathy is the usual culprit.
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Elderly patients with asymptomatic bacteriuria are not at risk for developing a UTI or renal
damage.
Treatment is necessary only when the patient has a symptomatic UTI or is at risk for developing
a more significant complication, such as if the patient has diabetes or is immunocompromised.
Recurrent infections that cannot be eradicated can sometimes be suppressed by antibiotics. This
should be avoided, however, unless the patient is symptomatic or developing complications,
because it can often lead to infection with resistant organisms.
Factors that would designate a UTI as complicated include:
 Age > 65 years
 Indwelling catheter
 Recent GU instrumentation
 Urinary calculi
 Renal impairment
 Prostatic involvement
 DM
 Renal transplant
 Neutropenia
 Recent antibiotic therapy
 Recurrent UTI
 Pregnancy (cannot use quinolones during pregnancy or sulfonamides near delivery date; cephalexin
is a reasonable 1st choice)
 Steroid therapy
 Immunocompromising disease
 Known structural or functional impairment
Patient Education
 Stay well hydrated
 In female patient: voiding after intercourse for prophylaxis
 Alternate contraception if recurrent UTI is associated with use of diaphragm
 Consider chemoprophylaxis with recurrent lower UTI
Follow-up:
 UTI in men and complicated UTI require initial culture, and repeat culture after completion of
therapy
 Thorough GU examination needed with:
 UTI in men
 Recurrent and complicated UTIs in females
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Interstitial Cystitis (IC)
Definition/Cause
 A chronic inflammatory condition of the bladder.
 Its cause is unknown.
 Unlike common cystitis, which is caused by bacteria and usually successfully treated with antibiotics,
IC is believe not to be caused by bacteria and does not respond to conventional ABT therapy.
 It is not a psychosomatic disorder nor is it caused by stress.
 It is not associated with bladder cancer.
Impact of Delayed Bladder Pain Syndrome/Interstitial Cystitis Diagnosis (Source: Evans, RJ, & Stanford, EJ.
(2006). J. Reprod Med. 51(3 suppl), 241-252.)
From the initial development of symptoms until the diagnosis 5-7 years later, patients:
 See at least 5 providers before the diagnosis
 Experience significant suffering and reduced quality of life
 May have unnecessary surgical procedures
Symptoms
 Frequency
o Day and/or night frequency of urination (up to 60 times/day in severe cases)
o In early or very mild cases, frequency is sometimes the only symptom
 Urgency
o May also be accompanied by pain, pressure or spasms
 Pain
o Can be in the lower abdominal, urethra, or vaginal area
o Pain also frequently associated with sexual intercourse (dyspareunia)
o Men with IC may experience testicular, scrotal and/or perineal pain, and painful ejaculation
 Other disorders
o Muscle and joint pain
o Migraines
o Allergic reactions
o GI problems
o IC sometimes associated with certain other chronic diseases and pain syndromes such as
vulvodynia, vulvar vestibulitis, fibromyalgia, chronic fatigue syndrome and IBS
 Triggers: diet, sexual activity, allergens
Diagnosis
 Urine culture to rule out bacterial infection
 Rule out other diseases and/or conditions that have symptoms resembling IC
o Bladder cancer
o Kidney problems
o Tuberculosis
o Vaginal infections
o STDs
o Endometriosis
o Radiation cystitis
o Neurological disorders
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Cystoscopy with hydrodistention under general anesthesia
o Done if no infection present and no other disorder is discovered
o If distention under anesthesia is not performed, diagnosis of IC may be missed
o Cystoscopy during a routine office visit may not reveal the characteristic abnormalities of IC
and can be painful for those who have IC
o Necessary to distend the bladder under general or regional anesthesia in order to see the
pinpoint hemorrhages on the bladder wall that are the hallmark of this disease
o A biopsy of the bladder wall may be necessary at this time to rule out other diseases such as
bladder cancer and to assist in the diagnosis of IC
Treatment
 Oral medications
o Elmiron (pentosan polysulfate sodium)
 FDA approval in 1996
 Only oral medication approved specifically for use in IC
 Believed to work by repairing a thin or damaged bladder lining
o Antidepressants
 Tricyclic antidepressants such as Elavil (amitriptyline)
 Help with both the pain and frequency of IC
 Used for their anti-pain properties, not as a treatment for depression
o Other oral meds
 Anti-inflammatory agents
 Antispasmodics
 Bladder analgesics (such as Urimax)
 Antihistamines
 Muscle relaxants
 Bladder installations
o Bladder distention with water under general anesthesia (diagnostic and may be therapeutic
as well)
o DMSO (dimethyl sulfoxide) as anti-inflammatory
o BCG (bacillus Calmette-Guerin) experimental; to boost immune system
o Cystistat (hyaluronic acid) in clinical trial; replace defective lining of bladder
 Other treatments
o Diet
 Eliminating acidic, spicy foods may decrease severity of IC
 Smoking, drinking coffee or tea, and alcoholic beverages may aggravate IC
o Self-help
 Stress reduction, visualization, biofeedback, bladder retraining and exercise
o Electronic nerve stimulators
o Surgery (only if severe symptoms); cystectomy, urinary diversion
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Bladder Cancer
Source: Sharma, S, Ksheersagar, P, & Sharm, P. (October 1, 2009) Diagnosis and treatment of bladder cancer. American Family
Physician, 80(7), 717-723.
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2nd most common genitourinary malignancy
6th most prevalent malignancy in the US, accounting for approximately 7% of cancers in men and
3% of cancers in women
Primarily found in older persons (approx.. 80% of new cases occur in persons 60+ years of age)
Male: female 3:1
More prevalent in white persons, but mortality rates are higher in black persons due to delayed
diagnosis
Risk factors
o Cigarette smoking (50% of cases)…smokers have 4-7X greater risk than nonsmokers
o Occupational exposures, such as aromatic amines used in the manufacturing of chemical
dyes and pharmaceuticals and in gas treatment plants (5-10% of bladder cancers)
o Exposure of the bladder to radiation, often as treatment for other pelvic malignancies,
increases the risk of bladder cancer 5-10 years after treatment
o Chronic infection (bladder calculi, chronic bladder infection, genitourinary tuberculosis,
long-term indwelling catheter, schistosomiasis)
Clinical presentation:
o Painless hematuria
o Gross blood throughout micturition
 Note: incidence of bladder cancer in patient with gross hematuria is 20%
compared to only 2% with microscopic hematuria
o Symptoms of bladder irritation (urinary frequency and urgency) are more common in
patients with bladder carcinoma in situ.
o Obstructive symptoms if tumor is located near the urethra or bladder neck
o Advanced disease may present with flank pain caused by ureteral obstruction , or with
abdominal, pelvic, or bone pain from distant metastases
Diagnosis
o Careful history, including risk factor assessment
o Urinalysis with urine microscopy and a urine culture to R/O infection
o Urine cytology
o Cystoscopy
o Patients with bladder cancer should also have the upper urinary tract evaluated
o If possible metastasis, also check CBC, blood chemistry (including alkaline phosphatase),
LFTs, CXR, and CT or MRI of the abdomen and pelvis
 If alkaline phosphatase is elevated, a bone scan may be performed
Treatment
o Multidisciplinary, involving urology, pathology, and oncology
o Type of carcinoma determines treatment among these options: transurethral resection,
cystectomy, radiation, chemotherapy
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Source: Mulcahy, N. (May 20, 2015). First study on bladder cancers presenting as UTIs. Accessed via Medscape at
http://www.medscape.com/viewarticle/845081_print
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Clinical pearl: Persistent symptoms characteristic of UTI that do not improve with time or
treatment may be due to bladder cancer.
Because bladder cancer most commonly presents as hematuria, UTI-like symptoms do not
always raise suspicion for bladder cancer
Women have a longer interval from UTI to diagnosis of bladder cancer than men.
Overactive Bladder/Urinary Incontinence
Source: Rosenberg, MT, & Dmochowski, RR (February 2005). Overactive bladder: Evaluation and management in primary care.
Cleveland Clinic Journal of Medicine, 72(2), 149-156.
Definition, Prevalence, & Significance:
 Overactive bladder is defined by the International Continence Society as a feeling of urinary urgency
at least 4 times in the past month, with or without urge incontinence, usually with urinary frequency
(more than 8 micturitions per day) and nocturia, but without pathologic or metabolic factors that
would explain the symptoms.
 Urinary incontinence (UI) is defined as “involuntary loss of urine sufficient to be a problem”
 Because it is frequent and embarrassing, UI is often accepted, underreported and undertreated
(about 50% of individuals with UI have not reported their symptoms to an MD or NP). Only 15% of
people with overactive bladder seek treatment.
 Incidence and prevalence increase with age and are related to cognitive and functional impairments
 Affects approximately 15-30% of noninstitutionalized older persons (19% of men, 39% of women)
 In nursing facilities between 50-70% of the 1.5 million residents are incontinent of urine (30% of this
group also experience fecal incontinence) due to functional dependency
 Social and psychological impacts of UI:
 Significant changes in social activities outside of the home
 Depression
 Social isolation
 Anxiety about potential disclosure to friends that UI is a problem
 Embarrassment about accidents in public
 Enforced changes in sexual activity
What is needed to maintain continence?
 Integrity of the bladder and urethra
 Intact neurological system that provides voluntary and coordinated control of voiding
 Pattern of urine production
 Desire and physical capability of the person to perform the activities associated with normal
toileting
Spinal reflex contraction impulses are continually generated between the spinal column and the bladder.
Continuous inhibitory signals from the brain (in the pons) normally prevent these contraction signals
from causing bladder contractions.
 In older persons suffering progressive brain failure or other cerebral change, the loss of these
inhibitory signals can, when combined with other predisposing factors, result in enough of a bladder
contraction to provoke leakage.
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Some apparent “stress incontinence,” in which the individual experiences urine leakage after
coughing or some other sharp increase in intraabdominal pressure, is in fact caused by uninhibited
bladder contractions.
** An important factor in women is loss of the vesicourethral angle (the angle at the juncture of the
bladder and the urethra) as a result of overstretching of pelvic muscles during childbirth and relaxation
of pelvic muscles after menopause related to estrogen deficiency.
Predisposing and Age-Related Factors in Urinary Incontinence:
 Increased residual urine
 Diminished bladder capacity
 Decreased bladder sensitivity
 Detrusor instability
 Prostatic hypertrophy
 Increased nocturnal urinary output
 Prior childbirth
 Obesity
 Smoking
 Estrogen withdrawal and menopause
 Brain failure
 Dysmobility
Factors Precipitating Urinary Incontinence:
 Relocation
 Inappropriate environment
 UTI
 Other acute illness
 Intravesical lesions
 Medications
 Urinary obstruction
 Neurological lesions
 Atonic bladder (as with diabetic autonomic neuropathy)
 Reflex neurogenic bladder
 Uninhibited neurogenic bladder
 Detrusor-sphincter dyssynergia
Common Causes of Transient (Acute) Incontinence (fairly sudden or recent onset of symptoms):
 Delirium or confusional state
 Symptomatic urinary infection
 Atrophic urethritis or vaginitis
 Drugs
 Sedatives or hypnotics, especially long-acting agents
 Loop diuretics
 Anticholinergic agents
 Alpha agonists/antagonist
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 Calcium channel blockers
Psychological problems, including depression
Endocrine disorders (hypercalcemia, hyperglycemia)
Restricted mobility
Stool impaction or constipation (especially causes urge incontinence due to stool pressing on
bladder)
Types of Persistent Urinary Incontinence:
 Stress incontinence
 Leakage with physical activity or increased intraabdominal pressure (as with chronic obstructive
pulmonary disease and obesity)
 Small to moderate volume leaks
 Usually in daytime only; infrequently nocturnal
 Due to sphincter incompetence; urethral instability
 Causes: pelvic prolapse in women, sphincter weakness or damage (such as following
prostatectomy, medications such as alpha-adrenergic antagonists)
 Urge incontinence
 Leakage following a strong uncontrollable urge to void or inability to delay voiding
 Moderate to large volume – a “gush”
 Urinary frequency, nocturia, possible suprapubic discomfort
 Due to detrusor overactivity (instability or hyperreflexia)
 Causes: CNS damage (stroke, Alzheimer’s, brain tumor, Parkinson’s disease), interference with
spinal inhibitory pathways, local bladder disorder, insulin-dependent diabetes mellitus,
depression, and medications including diuretics, caffeine, sedative-hypnotics, and alcohol
 Overflow incontinence
 Leakage without the urge to void, from a distended or obstructed bladder; intermittent or
continuous
 Volume varies
 Hesitancy, straining to void, weak or interrupted urine stream; occurs day or night
 Due to outlet obstruction or underactive detrusor
 Causes: Obstruction (BPH, bladder neck obstruction, urethral stricture), underactive detrusor (as
with herniated disk, spinal cord injury, diabetic neuropathy), anticholinergic/antispasmodic
drugs
 Functional incontinence
 Factors outside the urinary tract cause the loss of urine: mobility problems, cognitive deficit,
sedatives, environmental barriers, etc.
History:
Source: Diamond, S. (Jan 1, 2005). The 15-minute visit: Female urinary incontinence. Accessed at
http://www.patientcareonline.com
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In addition to HPI, the past medical history (checking for points mentioned above) is very
important
OB/GYN history: number and timing of pregnancies, method of delivery, history of pelvic
surgeries (all of which may weaken abdominal musculature)
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Bowel and bladder history; 24-hour micturition diary (frequency of leakage, time of food drink,
and activities)
Functional limitations, as with elderly patient with arthritic joints, may prevent the patient from
having enough time to manage all of the necessary steps of toileting
Physical Exam:
 Abdominal exam: check for increased abdominal fluid or organomegaly
 Pelvic exam: check for cystocele, atrophic vaginitis, infection; ask patient to cough and check for
urine loss
 Neurological: Deep tendon reflexes to evaluate lumbosacral plexus
Diagnostic Tests:
 U/A
 Postvoid residual measurement
 Three measurements between 50 and 200 ml is normal, but consistently above 100 ml should
be closely monitored
 Simple cystometry to evaluate bladder filling, storage, and emptying
 Abnormal findings include first desire to void at < 100 ml, pain or incontinence during filling, a
bladder capacity of < 400 or > 650 ml
 Uroflowmetry (listen while the patient voids)
 Should be smooth, uninterrupted, and initially strong
 Urodynamic studies (reserved for those unresponsive to a trial of treatment for the type of UI
diagnosed or where surgery is anticipated)
Treatment for Urinary Incontinence: Primary methods of treatment are behavioral, not pharmacologic.
Behavioral Treatment (educating the patient about UI to change the individual’s response to UI
symptoms)
 Maintain a bladder schedule (fixed interval, e.g., every 2-3 hours -- voiding too often or too little can
cause deconditioning of the bladder)
 Bladder training (progressively longer intervals)
 Promote fluid intake (many patients deliberately restrict their intake to reduce “accidents.”) –
concentrated urine can produce debris or in itself can be a bladder irritant.
 ½ the body weight in pounds is the number of ounces of liquid needed per day
 Avoid bladder irritants such as caffeine, tomatoes, citrus fruits, Equal
 Promote bowel regularity (constipation makes bladder symptoms worse)
 Practice urge control (urges are not a command to void, just a reminder that the bladder is filling)
 Do pelvic muscle exercise (30-80/day)
 Kegel exercises can decrease incontinency number (stress, urge) by ½ (whether “wet” type due
to leaking or “dry” type due to whether can make it to the bathroom in time)
 Electrical simulation treatment (with implants)
 “Double voiding” can reduce residual volume, decreasing the reservoir for infection and the
constant presence of urine available for leakage
 Most elderly men should sit down to urinate; it is safer, and it ensures the bladder is more fully
emptied each time.
 Pelvic floor dysfunction physical therapy
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Pharmacological Treatment
 For bladder wall:
 First line: anticholinergics
 Most commonly used: oxybutynin [Ditropan, Ditropan XL], tolterodine [Detrol, Detrol LA]
 Others used: trospium chloride (Sanctura), solifenacin (Vesicare), darifenacin (Enablex) and
oxybutynin patch (Oxytrol) Most recently approved: fesoterodine (Toviaz)
 NOTE: oxybutynin and tolterodine can precipitate anticholinergic psychosis
 Beta3-receptor agonists: mirabegron (Myrbetriq) (approved in 2012)
 Tricyclics (imipramine, doxepin)
 Can cause cardiac dysrhythmias and mental status changes; use with caution in elderly
patients
 Detrusor injections of botulinum toxins (for adults with OAB who cannot use, or do not
adequately respond to, anticholinergic medication)
 For urethra: alpha-adrenergics (pseudoephedrine), estrogen, alpha-blockers (Minipress, Hytrin),
central relaxants (baclofen [Lioresal], dantrolene [Dantrium], diazepam [Valium])
Surgical
 Artificial urinary sphincters
 Prostatectomy or TURP
 Dilation of urethral stricture
 Circumcision
 Penile reconstruction
 Urinary diversion
 Suprapubic catheter
Equipment and Devices
 Absorbent products
 Skin care
 Devices and urinals
 External catheters
 Indwelling urethral catheters
 Intermittent catheterization
Complications (From: Rosenberg & Dmochowski, page 150)
 Physical comorbidities and consequences of incontinence, such as skin ulceration, UTI, increased
incidence of falls and fall-related fractures, and sleep disturbances
 Psychological and lifestyle-related consequences include restricted mobility, impaired work
productivity, social isolation, impaired sexual functioning, and depression, with a significant
reduction in health-related quality of life.
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Pyelonephritis
Definition: Acute pyelonephritis (APN) is an acute infection of the upper urinary tract (collection system
and renal parenchyma)
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Usually occurs when colonic bacteria ascend through the urinary tract to invade the renal
parenchyma
More common in females due to short length and position of urethra
E. Coli most common cause (others include Proteus, Klebsiella, Staphylcoccus saprophyticus, and
Enterococcus
Key Symptoms:
 Fever (101-105 degrees)
 Chills
 Dysuria, frequency, or urgency
 Back or flank pain
 Nausea or vomiting
Key Signs:
 Fever
 CVA tenderness
(Note: Cystitis: no fever, no CVA tenderness)
Conditions that can be confused with APN include:
 PID
 Acute appendicitis
 Acute cholecystitis
 nephrolithiasis
Urinalysis: (+) leukocytes, (+) nitrite, may have WBC casts
Treatment:
 Factors favoring hospitalization include:
 Geriatric age group
 Underlying medical condition such as DM or pregnancy
 Male gender (higher frequency of anatomic abnormality)
 Known GU tract abnormality
 Uncontrolled N & V
 Signs of possible sepsis (hypotension, altered mentation)
 Pregnancy
 Poor social support
 Unable to comply with treatment
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Consider outpatient management for otherwise healthy young females who are reliable and who
are tolerating oral intake.
P a g e | 18
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Drug of choice (for outpatients): fluoroquinolones, trimethoprim-sulfamethoxazole, amoxicillinclavulanate
Treat 10 days (in less ill patients) to 14 days (in more ill or pregnant patients).
Follow-Up:
 Brief visit (or at least phone follow-up) after 1-2 days to document clinical improvement
 Failure to improve or worsening symptoms after 48-72 hours of outpatient treatment may represent
obstruction or abscess (will need ultrasound or IVP).
 A “test of cure” urine culture should be obtained approximately 2 weeks after the completion of
antibiotic therapy.
Glomerulonephritis (GN)
Etiology: either idiopathic (due to primary kidney disease) or secondary (associated with a systemic
disease such as lupus or infectious such as poststreptococcal GN (80% of these cases occur in children)
Key Symptoms:
 SOB, leg or facial edema
 Dark urine (“Coke-colored”)
 Symptoms suggesting secondary GN:
 Pharyngitis or skin infection 2-3 weeks earlier (suggests poststreptococcal GN)
 Joint pain (suggests lupus nephritis, cryoglobulinemia, or polyarteritis nodosa)
 Hemoptysis (suggests Wegener’s granulomatosis, Goodpasture’s syndrome)
 Sinusitis (suggests Wegener’s granulomatosis)
 Fever (suggests endocarditis, lupus nephritis)
 Heart murmur (suggests endocarditis)
Diagnostic Tests:
 Dipstick (proteinuria +/-)
 U/A (asymptomatic hematuria, especially RBC casts)
 BUN, creatinine (GN frequently causes renal failure)
 CBC (anemia seen in many cases of GN; thrombocytopenia suggests lupus nephritis)
 24-hour urine for creatinine clearance and protein (protein excretion is usually < 3 gm, but a
minority of patients may be nephrotic)
 Blood cultures (to screen for endocarditis)
 Antistreptolysin O (ASO) titer, streptozyme titer (if elevated, suggests poststreptococcal GN)
 Serum antinuclear antibody (ANA) (positive at high titer in lupus nephritis)
 Serum complement (C3, C4, CH50) (low in poststreptococcal GN, endocarditis-associated GN, lupus
nephritis)
 Kidney biopsy (helps to define the etiology)
Treatment:
 No specific medical therapy indicated for poststreptococcal GN
 Appropriate antibiotic therapy required in endocarditis
P a g e | 19
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Prolonged treatment with corticosteroids and cyclophosphamide for lupus nephritis
Diuretics often needed to treat volume overload and hypertension
Dialysis may be required in patients with GN accompanied by severe renal failure
Diet: Dietary sodium restriction (2 gm/day) to prevent volume overload and hypertension
If patient is hyperkalemic, potassium restriction is also indicated
Follow-Up:
 Long-term follow-up as outpatients for adjustment of medications to produce and maintain a clinical
remission and monitor for med side effects
 Labs: U/A, BUN, creatinine, lytes, serum complement
Nephrotic Syndrome
From: Kodner, C. (November 15, 2009) Nephrotic syndrome in adults: Diagnosis and management. American Family
Physician, 80(10), 1129-1134.
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In nephrotic syndrome, a variety of disorders cause proteinuria, often resulting in marked
edema and hypoalbuminemia.
Most cases of nephrotic syndrome appear to be caused by primary (idiopathic) renal disease
(focal segmental glomerulosclerosis, membranous nephropathy, IgA nephropathy
Common secondary causes of nephrotic syndrome include diabetes mellitus (most common),
SLE, hepatitis B or C, use of NSAIDs, amyloidosis, multiple myeloma, HIV, and preeclampsia.
Presenting symptoms: progressive lower extremity edema, weight gain, fatigue
In advanced disease: periorbital or genital edema, ascites, pleural or pericardial effusion
o ** Persons who present with new edema or ascites, without typical dyspnea of heart
failure or risk factors of cirrhosis, should be assessed for nephrotic syndrome.
Lab findings
o Urine dipstick proteinuria of 3+
o Random urine protein/creatinine ratio of 3-3.5 represents nephrotic-range proteinuria
o Low serum albumin (< 2.5 g/dL)
o Severe hyperlipidemia (cholesterol > 300-400
Complications
o Venous thromboembolism due to loss of clotting factors in the urine
o Infection due to urinary loss of immunoglobulins
o Acute renal failure
Management
o Limit sodium intake to 3 g/day
o May need to restrict fluid intake to < 1.5 L/day
o Diuretics (target weight loss of 1-2 lb/day to avoid acute renal failure or electrolyte
disorders)
 Loop diuretics such as furosemide or bumetanide given IV
o ACE Inhibitor to reduce proteinuria and reduce risk of progression to renal disease
o Unknown benefit: albumin IV, corticosteroids, lipid-lowering treatment.
P a g e | 20
o
Anticoagulation? – for persons who are otherwise at high risk for thromboembolism
(based on previous events, known coagulopathy)
Nephrolithiasis (kidney stones, renal calculi)
Sources:
Hall, PM (October 2009). Nephrolithiasis: Treatment, causes, and prevention. Cleveland Clinic Journal of Medicine, 76(10),
583-598.
Frassetto, L, & Kohlstadt, I. (December 1, 2011). Treatment and prevention of kidney stones: An update. American Family
Physician, 84(11), 1234-1242.
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Lifetime prevalence of 10% in men, and 5% in women
Prevalence increasing in the US
Presentation: moderate to severe colic caused by the stone entering the ureter (stones in the
renal pelvis may be asymptomatic); often accompanied by hematuria, nausea or vomiting, and
malaise. Fever and chills may also be present
o Stones in proximal (upper) ureter cause pain in the flank or anterior upper abdomen
o Stones in the distal third of the ureter cause pain in the ipsilateral testicle or labia
o Stones at the junction of the ureter and the bladder often cause dysuria, urgency, and
frequency and may be misdiagnosed as a lower urinary tract infection
Absence of hematuria does not exclude urolithiasis
Differential diagnosis: MSK pain, herpes zoster, diverticulitis, duodenal ulcer, cholecystitis,
pyelonephritis, renal infarction, renal hemorrhage, gynecologic disorders, ureteral obstruction
Renal infarction (From: Burg, MD, & Groenewoud, HW (November 2004). Kidney stone or renal infarction?
Emergency Medicine, 47-51.)
o
o
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Some patients with renal infarctions may not have flank pain (probably underdiagnosed)
Cardiac disease of various types predisposes patients to emboli that are the major cause
of renal infarctions
o A CT scan will almost always definitively diagnose a renal infarction
 ** If renal infarction is being pursued via CT, IV contrast must be given, although
it is not needed to visualize kidney stones
o Severe hypertension may occur
 If entire kidney has been infarcted, a total nephrectomy is commonly performed
to relieve the extreme renovascular hypertension
Evaluating acute renal colic: obtain CBC, UA, chemistry, CT scan
Management of acute stone events
o Most are smaller than 5 mm and will pass without interventions
o Larger stones (but less than 1 cm) may require lithotripsy
o Stones larger than 1 cm may require lithotripsy or ureteroscopy
o Pain management: parenteral NSAIDs often as effective as narcotics
o Antispasmodies to facilitate stone passage
 Alpha blockers (doxazosin, tamsulosin)
 Calcium channel blockers (nifedipine [Procardia, sustained release])
P a g e | 21
o
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Induce high urine flow with oral intake of at least 2-3 L of fluids/24 hours to ensure a
urine output of at least 2 L/day
o Stone analysis should always be done whenever stone material is available (Strain the
urine!)
Prevention of recurrent stones
o Stones recur in 30-50% of patients within 5 years
o Increase daily fluid intake
o For prevention of calcium phosphate and struvite stone, acidify urine (lower than 7)
 Cranberry juice: at least 16 oz/day
 Betaine: 650 mg orally 3 times/day with meals
o For prevention of calcium oxalate, cysteine, and uric acid stones, urine should be
alkalinized
 Potassium citrate 10-20 mEq orally with meals
 Calcium citrate: two 500 mg tablets/day with meals
o If found to have hypercalciuria, treat with high fluid intake, dietary sodium restriction,
and thiazide diuretics (calcium restriction is not advised)
 Consider primary hyperparathyroidism: Check intact parathyroid hormone level
Renal Cell Carcinoma (RCC)
Source: Curti, BD (July 7, 2004). Renal cell carcinoma. JAMA, 292(1), 97-100.
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Accounts for 3% of adult malignancy and 90-95% of neoplasms arising from the kidney
6th leading cause of cancer death in the US
25-39% of patients with RCC are asymptomatic with the diagnosis made incidentally from a
radiologic study obtained for other reasons
Frequently, the first symptoms are from metastatic lesions
Surgery is the treatment of choice for localized disease; no proven role for radiation or
chemotherapy
25-30% of patients have metastatic disease at diagnosis and more than 95% of these have
multiple metastases
o Palliative nephrectomy may be considered for alleviation of pain, hemorrhage, malaise,
hypercalcemia, erythrocytosis, or hypertension in patients with metastatic disease
Proteinuria
Sources:
Kashif, W. Siddiqi, N, Dincer, AP, Dincer, HE, & Hirsch, S. (June 2003) Proteinuria: How to evaluate an important finding.
Cleveland Clinical Journal of Medicine (70)6, 535-546.
Eknoyan, G (June 2003). On testing for proteinuria: Time for a methodical approach. Cleveland Clinic Journal of Medicine
(70)6, 493-501.
“Proteinuria is often transient and benign, but persistent proteinuria can be a manifestation of a
systemic disease.” (Kashif, p. 535)
P a g e | 22
Summary of evidence (Eknoyan, p. 493):
 Even relatively small increases in protein or albumin in the urine are an early sign of kidney
injury and often precede any detectable change in the serum creatinine concentration or
glomerular filtration rate.
 Protein in the urine is more than a marker: persistently high levels damage the kidney and
contribute to progressive loss of kidney function
 In persistent proteinuria, the amount of protein excreted bears a direct correlation to the rate of
loss of kidney function
 Interventions that reduce the amount of protein in the urine in persistent proteinuria retard the
progression of chronic kidney disease
 Proteinuria is a strong and independent predictor of increased risk for cardiovascular disease
and death, especially in people with diabetes, hypertension or chronic kidney disease the
elderly (may be surrogate marker for progressive atherosclerosis)
 The amount of protein excreted shows a strong and close correlation with the risk of death from
cardiovascular disease at all levels of excretion
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Normal rate of protein excretion in healthy adults is < 150 mg/day
o < 30 mg of this is albumin, which has a molecular weight just big enough to keep it from
passing through the normal, intact glomerular membrane
o The rest is composed of different proteins and glycoproteins from tubular epithelial cells
(Eknoyan, p. 493)
Mechanisms of proteinuria (Kashif, pp. 535-536)
1. Increased glomerular filtration of normal plasma proteins due to altered glomerular
permeability (glomerular disease)
2. Inadequate tubular reabsorption of the small amounts of normally filtered proteins
(tubulointerstitial diseases)
3. Overflow of elevated normal or abnormal plasma proteins (plasma cell dyscrasias)
4. Increased secretion of tissue proteins from the epithelial cells of the loop of Henle (TammHorsfall proteinuria)
Approach to a patient with proteinuria (Kashif, p. 537)
 After a positive dipstick test (+ proteinuria), check for conditions that can cause false-positive results
such as:
o Highly alkaline urine (pH > 7)
o Concentrated urine
o Gross hematuria
o Mucus, semen, or leukocytes
o Iodinated contrast agent
o Contamination with chlorhexidine or benzalkonium
 If false positive likely, repeat the dipstick after the condition resolves
P a g e | 23
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If false positive is NOT likely, check for conditions that alter renal hemodynamics such as exercise,
febrile illness, congestive heart failure
o If one of these conditions is present, reassure the patient for now and repeat the urine after
the condition resolves (1-2 weeks)
o If these conditions are absent, repeat the dipstick test
 If the proteinuria is not present (“nonpersistent proteinuria”), then just reassure the
patient
 If the proteinuria IS present (“persistent proteinuria”), the order a 24-hour urine
protein or spot urine protein-creatinine ratio
1. If non-nephrotic-range proteinuria (<3.5 g/day) or the proteincreatinine ratio is < 3.5, perform two sequential 12-hour urine
collections to rule out postural proteinuria
1. If postural, reassure patient
2. If nonpostural OR if the 24 hour urine protein showed
nephrotic-range proteinuria (>3.5 g/day) or the proteincreatinine ratio was >3.5, start workup for renal or systemic
disease. If no system disease, presume primary renal and
biopsy for confirmation.
Review National Kidney Foundation guidelines: “Practical Approach to Detection and Management of
Chronic Kidney Disease for the Primary Care Clinician at http://www.amjmed.com/article/S00029343(15)00855-4/pdf
Microalbuminuria
Source: Tagle, R, Acebedo, M, & Vidt, DG (March 2003). Microalbuminuria: Is it a valid predictor of cardiovascular risk?
Cleveland Clinic Journal of Medicine, 70(3), 255-261.
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Microalbuminuria is defined as albumin excretion of 30-300 mg/24 hours or an albumin-tocreatinine ration > than 30 mg/g in a first morning midstream sample.
Predictor of cardiovascular events in high-risk populations
Assess for microalbuminuria in:
o Patients with diabetes type 2
o Older patients with diabetes type 1
o Older patients with hypertension ( ≥ 160/100 mm Hg)
Remember, urine dipstick can only detect albumin at levels greater than 30 mg/dL
(approximately 300 mg/24 hours). So (+) protein on a urine dipstick is actually
macroalbuminuria.
Chronic Kidney Disease (CKD)
Read excellent article “Chronic Kidney Disease: Detection and Evaluation” available at
http://www.aafp.org/afp/2011/1115/p1138.pdf
P a g e | 24
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Note that the diabetes and hypertension are the two primary causes of kidney disease.
o If using a diuretic in treatment of hypertension, the level of GFR impacts the choice of
diuretic
 If eGPR is ≥ 30 mL/min, use a thiazide-type diuretic
 If GFR is < 30, use a loop diuretic such as furosemide
Serum creatinine is a poor screening test for mild disease….patients can have a significant
decreases in GFR while the creatinine remains within normal limits.
o This is most common in the elderly, those with low muscle mass, and women
o Need to calculate the GFR via the MDRD formula or the Cockroft-Gault formula (eGFR
calculators available as app; see https://www.kidney.org/apps/professionals/egfrcalculator
Remember our hematological content in Pathophysiology and earlier this semester? Don’t
forget about anemia of chronic disease which can occur with chronic kidney disease.
o
Source: Dalton, C., & Schmidt, R. (March 2008). Diagnosis and treatment of anemia of chronic kidney
disease in the primary care setting. The Journal for Nurse Practitioners,194-200.
o
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Anemia may develop before CKD is recognized. Hgb decreases significantly with even
mild impairment of kidney function
o Prevalence of anemia (Hgb < 12 g/dL) increases with advancing CKD stages (from 27% in
stages 1 and 2 [eGFR > 60] to 76% in stage 5 [eGFR < 15]
 Identification and clinical evaluation: Screening for anemia (in all patients with
CKD, diabetes, and hypertension)
 Kidney function assessment: calculate eGFR, check for proteinuria/albuminuria
via dipstick
 Hematological workup: CBC, absolute reticulocyte count, serum ferritin
 Treatment:
 Target risk factors: tight control of BP, blood glucose, and proteinuria
 If Hgb < 11 treat with erythropoiesis-stimulating agents (epoetin alfa
and darbepoetin alfa). Check Hgb monthly to make sure Hgb does NOT
> 12
 Iron: oral supplements are first line therapy, but iron infusions
becoming more popular
 Nutritional supplements (folate, pyridoxine, vitamin B12 needed in
malnourished patients
End stage renal disease (ESRD)/renal failure: a medical condition in which a person’s kidney’s
cease functioning on a permanent basis leading to the need for a regular course of long-term
dialysis or a kidney transplant to maintain life. (Stage 5)
o
Source: Raghavan, D., & Holley, J.L. Conservative care of the elderly CKD patient: A practical guide. Adv
Chronic Kidney Dis. 2016 Jan;23(1):51-6.
o
Symptoms in patient with ESRD are caused by factors related to the disease process
(metabolic derangements), comorbid illnesses, and factors related to treatment, most
commonly, dialysis
Symptoms include pain, fatigue, sleep disturbance, pruritus, anorexia
o
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Resources are available from the National Kidney Foundation at
https://www.kidney.org/professionals/guidelines/guidelines_commentaries/chronic-kidney-diseaseclassification
Disorders Involving Scrotal Contents
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Varicocele
Definition: an abnormal degree of venous dilatation in the pampiniform vascular plexus of the
scrotum
Cause unknown but possibly due to valvular incompetence in the internal spermatic veins
Often asymptomatic
 May experience heaviness in the scrotum and/or rarely a dull ache
 Patient may be concerned about many dilated and engorged veins in the scrotum
Examine patient while standing (to accentuate the dilated veins)
Valsalva maneuver or coughing may help identify the veins
> 90% of varicoceles occur on the left
 If sudden appearance of a right-sided varicocele, rule out obstruction of right spermatic vein due
to retroperitoneal neoplasm
On palpation a varicocele often feels like a “bag of worms”
Tests: scrotal ultrasonography, spermatic venography “gold standard”
Treatment: surgical ligation, laparoscopic varicocelectomy, percutaneous varicocele occlusion
No medication, diet, or activity changes needed
Hydrocele
 A cystic fluid accumulation in the tunica or processus vaginalis
 May be congenital or occur after epididymitis, orchitis, testicular trauma, radiation therapy, or
unknown etiology
 Symptoms: usually none, may have “heaviness” in the scrotum
 Clinical findings: nontender, rounded scrotal mass that transilluminates
 Usually more prominent anteriorly and may surround the testis
 Mass may be soft and cystic or large and tense
 Diagnostic tests:
 Aspiration of fluid may result in infection – avoid if possible
 Testicular sonography – to differentiate cyst from solid mass (to exclude cancer)
WARNING:
 An intratesticular mass or a mass adherent to the testicle is cancer until proven otherwise.
 If a hydrocele develops spontaneously between the ages of 18 and 35, careful evaluation should be
made to exclude cancer.
 Treatment: If very tense, large – may require surgical repair. Otherwise, active therapy is not
required. An athletic supporter may relieve symptoms.
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Epididymitis
Two major forms: bacterial and sexually transmitted
 Sexually transmitted (usually < 35 years of age)
 Chlamydia, gonorrhoeae, ureaplasma, gram-negative rods
 Bacterial (seen with anatomic abnormalities)
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Usually > 35 year after prostatectomy, prostatitis, BPH
E. coli, Pseudomonas
Can also occur in children from pathologic connection from the GI or urinary tract to the
genital duct system
Amiodarone (Cardarone, Pacerone) – usually associated with bilateral epididymitis
Symptoms
 Gradual onset of scrotal pain that occasionally radiates to the lower abdomen
 Dysuria
 Urethral discharge
 Abdominal pain
Key signs
 Epididymal tenderness and swelling
 Scrotal erythema and edema
 Normal cemasteric reflex
 Pain relief with testicular elevation (Prehn sign)
Diagnostic Tests
 CBC – increased WBC count with shift to left
 Gonorrhea and Chlamydia culture
 Urethral smear (collect before collecting urine)
 U/A, C&S
 Ultrasound of scrotum—very important
 Findings: enlarged, thickened epididymis with increased blood flow on color Doppler
 Radionuclide scanning
Treatment
 Chlamydia: Floxin, doxycycline, or erythromycin X 10 days
 Gonorrhea: Rocephin IM X 1 dose or ampicillin po for 10 days
 Combination therapy: Suprax 400 (or Cipro 500) plus Zithromax 1 gram
 Bacterial: Cipro, Bactrim DS
 NOTE: If unsure of etiology, treat with Rocephin and doxycycline while awaiting culture results.
 Treat partner for STDs
 Oral NSAID
 Bed rest for 3-4 days with scrotal elevation on towel until pain is gone
 Roomy athletic supporter
 Ice in early phase, heat in later phase
 Avoid sexual activity and physical strain
Complications
 Testicular atrophy (occurs in 2/3) possibly due to partial vascular thrombosis of the testicular artery
 Infertility (50% in bilateral epididymitis)
 Abscess and infarction (5% of cases)
 Chronic epididymitis
P a g e | 27
Testicular Torsion
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Most common cause of acute scrotum
With scrotal pain/masses, this is the first diagnosis to rule out
Differentiate from other scrotal problems
 Testicular torsion presents abruptly with pain
 Epididymitis incarcerated hernia, and viral orchitis present gradually with scrotal pain
 Hydrocele, testicular tumor, varicocele, and epididymal cyst are typically painless unless there is
a rapid increase in size
Clinical findings
 Initially, the testicle is diffusely tender with hemiscrotal edema and erythema. Eventually, the
entire scrotum becomes tender, edematous, and erythematous.
 The testicle is elevated in the scrotum and may lie in a horizontal position.
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Elevation of the testicle above the pubic symphysis does not relieve the pain (negative Prehn’s
sign); elevation may increase pain
Abdominal pain, nausea, and vomiting
Absent cremasteric reflex
Usually in teenagers and men in their 20s
Ultrasound findings: normal-appearing testis with decreased blood flow on color Doppler

If found, REFER IMMEDIATELY! This is a surgical emergency.
 Testicular salvage rate is 90% if detorsion occurs less than 6 hours from the onset of symptoms,
but it falls to 50% after 12 hours and to < 10% after 24 hours.
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Evaluation of Acute Scrotal Pain
Algorithmic approach to the evaluation of the patient with acute scrotal pain. (From: Ringdahl, E, & Teague, L. (Nov.
15, 2006). Testicular torsion. American Family Physician, 74(10), 1739-1743.)
Testicular Cancer
Prevalence
 Most common malignancy in men 20-35 years of age
 Approximately 4 of every 100,000 US males develop testicular cancer
 Accounts for 1-2% of all male cancers
 Incidence has doubled over past 40 years and continues to rise, particularly in white men
 When diagnosed early, has a cure rate of nearly 99%
Risk Factors
 History of cryptorchidism increases risk for testicular cancer 3-17 fold
 Relative risk can be reduced by surgical repair (orchiopexy) before puberty
 Risk back to normal if corrected before age 8
 Family history
 Infertility
 Tobacco use
 White males affected 4.5 times more frequently than black males
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Clinical Presentation
 Testicular nodule or thickening
 Increased size or heaviness of the scrotum
 May be asymptomatic
 Often painless
 10% present with symptoms of epididymitis
 5% present with symptoms of metastases:
 Gastrointestinal symptoms
 Gynecomastia
 Lumbar back pain
 Neck mass
 Respiratory symptoms (cough, hemoptysis, dyspnea)
 May have supraclavicular lymphadenopathy, abdominal, groin or flank masses
Testicular changes are usually found during self-examination, after testicular trauma, or by a sex
partner.
Self-Examination
 90% of testicular cancer is identified by the patient
 Study of college students: 87% of the men had never heard of TSE. Of these 89% stated that if they
were given information about TSE, they would practice it monthly.
 Mnemonic:
 T = timing, once a month for 3 minutes
 S = shower, where the warmth of the shower relaxes the scrotal sac
 E = examine, check for changes and report them immediately
Diagnostic Tests: Scrotal ultrasound
Treatment:
 Primary treatment: radical inguinal orchiectomy, which includes removal of testicle and
spermatic cord
 Further treatment is determined by microscopic diagnosis and staging
o Observation
o Dissection of retroperitoneal lymph node
o Radiation
o Chemotherapy
Prognosis:
 Early cancer without metastases: 99% cure rate
 Metastasis to retroperitoneal lymph nodes: 91-96% 5-year survival
 Advanced metastatic cancer: 66-94% 10-year survival
 Also: increased risk of cancer in contralateral testicle.
P a g e | 30
Penile Problems
Balanitis
Definition: Inflammation of the skin covering the glans penis
Signs/symptoms: penile pain, dysuria, drainage at site of infection, erythema, prepuce swelling,
ulceration, plaques
Most common causes:
 Allergic reaction (condom latex, contraceptive jelly)
 Fungal (Candida albicans) and bacterial infections
 Fixed drug eruption (sulfa, tetracycline, barbital)
Risk factors: presence of foreskin; oral antibiotics in male infants
Treatment:
 Fungal: Lotrimin 1% bid or nystatin bid to qid to affected area
 Bacterial: bacitracin qid or Neosporin qid to affected area
 Dermatitis: topical steroids qid to affected area
Follow-up: Every 1-2 weeks until etiology has been established. Persistent balanitis may require biopsy
to rule out malignancy.
Prevention/Avoidance: proper hygiene, avoidance of allergens, circumcision
Possible complications: meatal stenosis, premalignant changes from chronic irritations, UTIs
** Increased risk of penile cancer with smegma (substance under foreskin); nontender lesion (pimple,
wart), typically near end of penis  biopsy needed
Penile lesions
Reference article: Teichman, J.M.H., Sea, J., Thompson, I.M., & Elston, D.M. (January 15, 2010)
Noninfectious Penile Lesions. American Family Physician, 81(2), 167-174 available at:
http://www.aafp.org/afp/2010/0115/p167.pdf
Erectile Dysfunction
Definition
The persistent inability to attain or maintain penile erection sufficient for sexual intercourse
Demographics
An estimated 10-20 million American men have some degree of erectile dysfunction
P a g e | 31
Causes
 Organic (80% of cases)
o Vasculogenic (arterial or inflow disorders most common)
 Atherosclerosis
 Hypertension
 Hyperlipidemia
 Long-term smoking
o Neurogenic
 Stroke
 Spinal cord injury
 Complication of prostate surgery
 Diabetes
 Long-term heavy alcohol use
o Hormonal
 Low testosterone
o Medications
 Antihypertensives
 Psych meds
 Antiandrogenic meds (digoxin, Histamine 2-receptor blockers)
 Others (alcohol, ketoconazole, niacin, phenobarbital, phenytoin)
 Psychogenic (20% of cases)
o Depression
o Anxiety
o Social stressors
Treatment
 Lifestyle changes
o Smoking cessation
o Decreased alcohol intake
o Stress reduction
o Strengthening of relationships
 Adjustment of regularly used medications
 Identification and treatment of underlying medical conditions
 Oral medications
o Sildenafil (Viagra)
o Tadalafil (Cialis)
o Vardenafil (Levitra)
 Vacuum devices
 Intrapenile or intracavernosal medication
MEN WITH DIABETES WHO ALSO HAVE TROUBLE GETTING AN ERECTION MAY HAVE HEART DISEASE
AND NOT EVEN REALIZE IT.
o
P a g e | 32
Prostate Problems
Prostatitis
Etiology
 Most common and important causes of UTI in adult males
 Most common causative agents include gram-negative bacilli (E. coli), enterococci, Chlamydia,
ureaplasma
Symptoms
Acute bacterial prostatitis
 Fever, chills, malaise, myalgias
 Decreased urine flow, dysuria, perineal and back pain, nocturia, urinary outlet flow obstruction
Chronic prostatitis
 Dysuria
 Decreased flow
 Hesitancy
 Dribbling
 Possibly a low-grade fever
Nonbacterial prostatitis
 Similar clinical presentation to chronic prostatitis, but no evidence of UTI despite presence of
leukocytes in prostatic secretions
Clinical Findings/Key Signs
 Gentle rectal examination (do not massage the gland) reveals a swollen, exquisitely tender, and
boggy prostate gland
 Often bladder distention is noted on abdominal examination
 “Appears ill” with acute prostatitis
Diagnostic Tests
 U/A, C&S
 Expressed prostatic secretions when diagnosis is in doubt
 Possibility of bacteremia with acute bacterial prostatitis
Differential Diagnosis
 Acute prostatitis is straight-forward and readily evident with the findings of fever, dysuria, and
tender prostate
 Chronic prostatitis may be more difficult and should include differential diagnoses of:
 BPH
 Prostatic Ca
 Urethral stricture
 Bladder Ca
 Neurogenic bladder
 Interstitial cystitis
P a g e | 33
Diagnosis and Treatment of Acute Bacterial Prostatitis
Figure 2.
Diagnosis and treatment algorithm for acute bacterial prostatitis. (CT = computed tomography; IV = intravenously;
TMP/SMZ = trimethoprim/sulfamethoxazole [Bactrim, Septra].)
From: Sharp, VJ, Takacs, EB, & Powell CR (August 15, 2010), Prostatitis: Diagnosis and treatment.
American Family Physician, 82(4), 397-406.
P a g e | 34
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Some authors suggest suppression therapy to last approximately 3 months, using Bactrim DS , Cipro
500 mg, or doxycycline 100 mg only once a day
Diet: avoid irritative substances: caffeine, spicy foods, OTC decongestants
Warm sitz baths may help if having difficulty voiding
No activity restriction; normal sexual activity
Follow-Up
 Acute prostatitis: re-evaluate 48-72 hours after initial evaluation or after discharge from hospital
 Subsequent follow-up evaluations in 2-3 weeks, and then 1 month after discontinuing antibiotics
Benign Prostatic Hyperplasia (BPH)
Definition: Benign adenomatous growth of prostate which may result in bladder outlet obstruction
 The prostate grows from 1 g at birth to a usual adult weight of about 20 g.
Predominant age:
 Rarely seen in men < 40
 Seen in 50% of men > 50; 80% of men > 70
Causes:
Exact etiology unknown, but evidence suggests BPH arises from a systemic hormonal alteration which
may or may not act in combination with growth factors stimulating glandular hyperplasia
Signs/Symptoms:
 Obstructive symptoms due to mechanical obstruction and/or detrusor muscle decompensation
 Decrease force or caliber of stream
 Hesitancy
 Post-void dribbling
 Sensation of incomplete bladder emptying
 Overflow incontinence
 Inability to voluntarily strop stream
 Urinary retention
 Irritative symptoms due to incomplete bladder emptying and/or detrusor muscle instability
 Frequency
 Nocturia
 Urgency
 Urge incontinence
 Others
 Gross hematuria
 Observation of weak stream
 Distended bladder (> 150 cc in order to detect by percussion)
 Increased post-void residual (> 100 cc)
 Prostate enlarged (normal 20 gram prostate – size of horse chestnut)
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Clinical clues suggesting renal failure due to obstructive uropathy (edema, pallor, pruritus,
ecchymoses, nutritional deficiencies, etc.)
American Urological Association (AUA) symptom index score > 7 (test attached)
 Mild symptoms (score 0-7)
 Moderate symptoms (score 8-19)
 Severe symptoms (score 20-35)
Diagnostic Tests:
 BPH is a pathologic diagnosis – lab data is only suggestive
 U/A – pyuria, pH changes due to chronic residual urine
 Elevated serum creatinine (if obstructive uropathy present)
 C&S may be positive (chronic residual urine)
 PSA may be elevated but usually < 10 ng/ml
 Increased post-void residual
 Transrectal prostate ultrasound
 Confirmation obtained by biopsy, resection
Treatment:
 Medications (when no strong indications of surgery exist or patient refuses surgery)
 Alpha adrenergic antagonist: terazosin [Hytrin], doxazosin [Cardura], tamsulosin [Flomax]
 Caution in patients with cardiac or cerebrovascular disease or those who operate machinery
 Hormonal (anti-androgens) agents: finasteride [Proscar] works best for larger prostates;
turosteride , flutamide [Eulexin], and leuprolide [Lupron] are rarely used; saw palmetto weak
 Hormones may cause impotence (except flutamide)
 The semen of men taking finasteride may cause effects on the fetus of pregnant sex
partners
 Surgery
 Transurethral resection of prostate (TURP)
 Transurethral incision of prostate (TUIP)
 Open prostatectomy (glands > 40 grams)
 Transurethral microwave thermotherapy (TUMT)
 Transrectal prostatic hyperthermia
 Transurethral laser induced prostatectomy (TULIP)
 Visual laser assisted prostatectomy (VLAP)
 Prostatic urethral stenting
 Transurethral electrovaporization of prostate (TVAP)
 Transurethral needle aspiration ablation of prostate (TUNA)
 Diet: avoid caffeinated or alcoholic beverages, excessively spiced foods
Follow-Up:
 AUA Symptom Index every 1-6 months
 Urodynamics every 3-12 months
 DRE yearly
 PSA yearly
P a g e | 36
Prostate Test (for urinary activities)
Adapted from the American Urological Association (AUA)
Symptom Index for BPH
Circle the numerical score for each question below:
1.
Over the last month or so, how many times did you most typically get up to urinate from the
time you went to bed at night until the time you got up in the morning?
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2.
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3.
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4.
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None (0)
1 time (1)
2 times (2)
3 times (3)
4 times (4)
5 or more (5)
Over the past month or so, how often have you had a sensation of not emptying your bladder
completely after you finished urinating?
Not at all (0)
Less than 1 time in 5 (1)
Less than half the time (2)
About half the time (3)
More than half the time (4)
Almost always (5)
Over the past month or so, how often have you have to urinate again less than two hours after
you finished urinating?
Not at all (0)
Less than 1 time in 5 (1)
Less than half the time (2)
About half the time (3)
More than half the time (4)
Almost always (5)
Over the past month or so, how often have you found that you stopped and started again
several times when you urinate?
Not at all (0)
Less than 1 time in 5 (1)
Less than half the time (2)
About half the time (3)
More than half the time (4)
Almost always (5)
P a g e | 37
5.
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6.
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7.
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Over the past month or so, how often have you found it difficult to postpone urination?
Not at all (0)
Less than 1 time in 5 (1)
Less than half the time (2)
About half the time (3)
More than half the time (4)
Almost always (5)
Over the past month or so, how often have you had a weak urinary stream?
Not at all (0)
Less than 1 time in 5 (1)
Less than half the time (2)
About half the time (3)
More than half the time (4)
Almost always (5)
Over the past month or so, how often have you had to push or strain to begin urination?
Not at all (0)
Less than 1 time in 5 (1)
Less than half the time (2)
About half the time (3)
More than half the time (4)
Almost always (5)
Total Score: _______
Score of 0-7:
Mild symptoms
Score of 8-19: Moderate symptoms
Score of 20-35: Severe symptoms
P a g e | 38
Prostate Cancer
Description:
The prostate is composed of acinar glands and their ducts arranged in a radial fashion with the stroma
containing blood vessels, lymphatics and nerves.
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
95% of prostate cancers are acinar adenocarcinomas
Degree of malignancy based on grading various stages:
 A1 A2, and B1, B2 = confinement within the capsule
 C1 = extension beyond the capsule
 C2 = involving the seminal vesicles
 D1 = metastatic disease in regional lymph nodes
 D2 = metastatic disease in bone or other organs
Signs/symptoms:
 May be asymptomatic early or late in the course of disease
 Induration of the prostate on DRE
 Hard prostate, localized or diffuse
 Bladder outlet symptoms
 Acute urinary retention
 Hematuria (rare)
 UTI
 Bone pain
 Weight loss
 Anemia
 SOB
 Lymphedema
 Neurologic symptoms
 Lymphadenopathy
Risk Factors:
 Age
 65-77% of prostate cancers occur in men > 65 years old
 < 5% occur in men 55 and younger
 Ethnicity
 Greatest risk: African Americans and Jamaican Americans
 Lowest overall risk: Asian Americans
 Family history
 Relative risk for prostate cancer in men with a first-degree relative (brother or father) is 2.5
times that of men without a family history
 Modifiable risk factors: diet and body weight
 Exposure to chemical carcinogens
P a g e | 39
Diagnostic Tests:
 Digital rectal exam (DRE)
 PSA elevated
 Free PSA – low in cancer
 Alkaline phosphatase, elevated with metastasis
 Biopsy (to be done if either the DRE or the PSA is abnormal)
 Gleason score***
 Bone scan to check for mets
Treatment:
 Over age 70: conservative or palliative treatment
 Radiation, external beam or brachytherapy with implants
 Total androgen ablation
 Flutamide (Eulexin) 250 mg. Tid
 Leuprolide (Lupron) 1 mg subcu daily or 7.5 mg IM depot monthly or goserelin (Zoladex) 3.6 mg
q 28 days
 Under age 70: aggressive surgery for cure
 Stages A-B and selected C under age 70
 Orchiectomy
Follow-Up:
 Routine clinical examination every 3 months X 1 year
 Routine clinical examination every 6 months X 1 year
 Annual examinations indefinitely
 PSA q 3 months X 1 year, q 6 months X 1 year, then yearly
 CXR, bone scan q 6 months X 1 year, then yearly
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PSA (Prostate-Specific Antigen)
Efficacy of PSA
 USPSTF Strength of Recommendation: D
 Test Sensitivity
o Overall: 79-82%
o Cancers >1 cm: 90%
o More sensitive than Rectal Exam (30% for 1 cm tumor)
o Much more sensitive than Acid Phosphatase
 Test Specificity = 59%
o High false positive rate
o Benign Prostatic Hyperplasia often increases PSA
 Positive Predictive Value (PPV) 32-40%
 Much more cost-effective than Mammography
 Outcomes uncertain despite effective screening
o Detection may not impact morbidity and mortality
Causes of elevated PSA
 Prostate Cancer
 Benign Prostatic Hyperplasia (BPH)
 Prostatitis
 Prostate inflammation, trauma, or manipulation
 Prostatic infarction
 Recent sexual activity
 Urologic procedures
o Cystoscopy
o Urinary Catheterization
Screening recommendations
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Most organizations do not recommend routine screening
o See Efficacy above
o US Preventive Task Force
o American College of Physicians
o American Society of Internal Medicine
o National Cancer Institute
o Centers for Disease Control and Prevention (CDC)
o American Academy of Family Physicians
o American College of Preventive Medicine
Organizations advocating screening
o American Cancer Society
o American Urological Association
o National Comprehensive Cancer Network
Screening (if performed)
o Men without risk factors: Age over 50 years
 Digital Rectal Exam yearly
 Prostate Specific Antigen (PSA) yearly
P a g e | 41
o
o
Men with risk factors: Age over 45 years
 Indications
 See Prostate Cancer for risks factors
 African Americans
 Young first degree relative with Prostate Cancer
 Digital Rectal Exam yearly
 Prostate Specific Antigen (PSA) yearly
Age over 70 to 75 years
 Discontinue PSA screening
Informed Consent Discussion with Patient
 Blood Test improves detection of Prostate Cancer
o PSA is twice as effective as rectal exam
 Early detection, however may not save more lives
o Small Prostate Cancer exists in 30% of men your age
o Only 3% of men die from Prostate Cancer
o Most Prostate Cancers do not affect men who have them
o Prostate Cancer most often affects those over age 70
 Not all PSA number increases are due to Prostate Cancer
 Increased PSA number requires evaluation
o Urology consultation
o Transrectal ultrasound with prostate biopsies
 Treatment for Prostate Cancer requires prostate removal
o Prostate removal is extensive surgery
 Death: 2%
 Impotence: 25%
 Urethral stricture: 18%
 Incontinence: 6%
o Prevents death in only 10% men with Prostate Cancer
Age specific Normal PSA values
Age
Normal PSA Values
White
African-American
Asian
40 to 49 years
PSA ≤ 2.5
PSA < 2.0
PSA < 2.0
50 to 59 years
PSA ≤ 3.5
PSA < 4.0
PSA < 3.0
60 to 69 years
PSA ≤ 4.5
PSA < 4.5
PSA < 4.0
70 to 79 years
PSA ≤ 6.5
PSA < 5.5
PSA < 5.0
P a g e | 42
Algorithm to evaluate PSA results
 PSA < 2 ng/ml
o Repeat PSA in 2 years
o Chance that PSA > 5 mg/ml in 2 years is <4%
 PSA 2.6 to 4.0 ng/ml
o Unclear guidelines as to approach this range of PSAs
o Age over 50 years should be considered for evaluation
 PSA 4.0 to 5.0 ng/ml
o Prostate Cancer "Curable" Range
 PSA >5.0 ng/ml
o Lower likelihood of Prostate Cancer "Cure"
Prognostic Predictive Value of PSA
PSA with associated Prostatectomy findings
PSA ≤ 4.0 ng/ml
Organ limited Prostate Cancer in 64%
PSA 4.0-10.0 ng/ml
Organ limited Prostate Cancer in 50%
PSA 10.0 to 20.0 ng/ml
Organ limited Prostate Cancer in 35%
PSA >100 ng/ml
Predicts bone metastases in 74% of cases
PSA in combination with Rectal Exam and Biopsy
PSA < 10 ng/ml
Organ limited disease in 60%
(Non-palpable, Low Gleason grade)
PSA >20 ng/ml
Organ limited disease in 10%
(Palpable, Gleason poor-moderate diff)
Free PSA (Free Prostate Specific Antigen)
Mechanism
 Free PSA increases more in Benign Prostatic Hypertrophy
 PSA associated with cancer is more protein bound
Indication
 Detection of Prostate Cancer when PSA 2.5 to 10 ng/ml
Efficacy
 Improved Specificity when combined with PSA
P a g e | 43
Interpretation
 Free PSA >27% with lower likelihood of Prostate Cancer
 Values suggestive of Prostate Cancer
o Total PSA 3.0 to 4.0 with Free PSA <19%
o Total PSA 4.0 to 10.0 with Free PSA < 17 to 24%
Other Male Health Issues
Andropause (age-related hypogonadism): decline in testosterone is men.
See Margo, K., & Winn, R. (May 1, 2006). Testosterone treatments: Why, when, and how? American
Family Physician, 73(9), 1591-1598. Available at http://www.aafp.org/afp/2006/0501/p1591.pdf
** Caution with patients with CV disease—increased risk of MI or stroke with use of testosterone
Health Care Screening for Men Who Have Sex with Men
Read: Knight, D. (May 1, 2004). Health care screening for men who have sex with men. American
Family Physician, 69(9), 2149-2156. Available at: http://www.aafp.org/afp/2004/0501/p2149.html
Gynecomastia
Read: Johnson, R.E., & Murad, M.H. Gynecomastia: Pathophysiology, evaluation, and management.
Mayo Clin Proc., November 2009;84(11):1010-1015. Available at:
http://www.mayoclinicproceedings.org/article/S0025-6196(11)60671-X/pdf
Male Breast Cancer
Read: Giordano, S.H . A review of the diagnosis and management of male breast cancer. The
Oncologist, 2005;10:471-479. Available at:
http://theoncologist.alphamedpress.org/content/10/7/471.full.pdf+html